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Primary Location:                       Additional Locations Only:

Type of Service:

Business Name:            Date: 9/7/2008

Primary Location Address:

City:    State:    Zip Code:

Mailing Address (If Different):

City:    State:    Zip Code:

Phone Number:        Fax Number:

Contact Name / Title:

E-mail:        Web Address:

1800HOMEHELP designated "Ring To" Phone Number:

Market Service Area(s) Requested (by Zip Code):
1. 2. 3. 4. 5.

Professionals License:

Name of Current Phone Service Providers:
Local      Long Distance:

Name of Major Suppliers:


List civic and/or professional organization involvement
by the business owner or representative:

List community and/or professional awards won by the business or its employees:

Profile for 1800HOMEHELP:

Services listed on 1800HOMEHELP:

Quality Assurance Requirements

Contractors License #:       Types:

How Many Years in Business?

Business License #:      City:     State:

Is the business a member of the Better Business Bureau?        YES                 NO

Does the business have a clear process for handling customer concerns? YES NO

Is the business adequately insured to indemnify employees and customers? YES NO

Current Claims Carrier:       Renewal Date:

Bond Carrier:       Renewal Date:

Claims History?

Is the business currently involved in litigation, unresolved complaints, Better Business
Bureau, or other agency complaints? YES NO If Yes Explain:

Trade References

Name:        Phone Number:

Address:

Name:        Phone Number:

Address:

Name:        Phone Number:

Address:

Name:        Phone Number:

Address:

Customer References

Name:        Phone Number:

Address:

Name:        Phone Number:

Address:

Name:        Phone Number:

Address:

Name:        Phone Number:

Address:

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